DIEP & Other Perforator Flaps

DIEP  /  SIEA  /  SGAP  /  TUG  /  PAP   Flaps

One of the most exciting new advances in cancer breast reconstruction following a mastectomy is the use of Perforator Flaps such as the DIEP (Deep Inferior Epigastric Perforator) Flap. While the DIEP is the most common and original of such procedures, there are also SIEA, SGAP, TUG, and PAP Flaps (see below). All of these flaps involve using the patient’s own tissues, from various parts of the body depending upon the type of Flap, to create a new breast. The techniques involved require microsurgical training and are therefore only done by a relatively small number of plastic surgeons around the country.

Not every patient is a candidate for a DIEP or other Perforator Flap, and each patient should consider all the available options before making a decision about reconstruction.

Dallas DIEP & SIEA Flaps

The most common of these are the DIEP/SIEA flaps. DIEP/SIEA flaps involve using tissue from the abdomen as is done with a TRAM flap (see Dallas TRAM Flap Reconstruction). However, with a DIEP or SIEA flap the abdominal muscles of the abdomen are left intact. The blood vessels needed to keep the flap alive are microsurgically dissected by the surgeon through the abdominal muscle, enabling the surgeon to use the overlying tissue without removing the abdominal muscle. The DIEP and SIEA flaps utilize the same tissues but involve somewhat different blood vessels. The determination as to which of these two flap types to use is made by the surgeon, often at the time of the surgery itself, and is based upon the best available vessels in a particular patient’s anatomy. Other than the different blood vessels used, the procedures are otherwise the same.

Dallas cancer breast reconstruction patients have the same long scar across the abdomen as those who have a TRAM flap (and the same scar as seen in a “tummy tuck”), and achieve much the same flatter abdominal contour after surgery. However, patients typically experience fewer complications due to muscle loss and have quicker recuperation periods than patients with TRAM flaps.

Currently, Dr. Duffy and Dr. McKane are among only a handful of surgeons in this part of the country regularly performing perforator flaps such as the DIEP and SIEA flaps. The Texas Center for Breast Reconstruction has the first surgeon to perform them in this part of the state. We are very excited to be able to offer this option to patients.

What Are The Advantages And Disadvantages Of DIEP/SIEA Flap Reconstruction?  


  • Since the reconstruction involves using the patient’s own tissues, the risks of implant reconstruction are avoided.
  • Most patients have less postoperative pain than after a TRAM flap and are therefore able to leave the hospital sooner, and return to normal activities quicker than after a TRAM flap.
  • Because the abdominal muscle is not removed, patients have less risk of developing hernias at the site where the flap is removed than patients who have had a TRAM flap.
  • It is typically easier to match the contralateral natural breast with the patient’s own tissue when compared with implant reconstruction.
  • Patients essentially end up with a “tummy tuck” at the same time as the breast reconstruction.


  • DIEP/SIEA flap reconstruction generally requires a longer and more difficult surgery at the first stage when compared with implants or TRAM flaps.
  • Patients will have a scar across the lower abdomen where the flap is obtained.

SGAP Flaps

The SGAP (Superior Glutetal Artery Perforator) and related IGAP flaps involve using tissue from the buttocks region to create the new breast. The same microsurgical technique is utilized as with the DIEP/SIEA. For patients who are unable to have a DIEP/SIEA, perhaps because of a prior abdominal surgery or because there is not sufficient abdominal tissue, the SGAP may be an option.

TUG Flaps

The TUG (Transverse Upper Gracilis) Flap and the related VUG or FDL Flap involve using the tissue from the inner thigh to create the new breast. This involves the same microsurgical technique as in the DIEP flaps but is an option for those who cannot use the abdominal tissue due to prior surgeries or insufficient tissue.

PAP Flaps

The PAP (Profunda Artery Perforator) Flap is yet another type of microsurgical flap like that of the DIEP except that it involves using tissue from the back of the thigh, beneath the buttock crease. It represents yet another option for those with insufficient abdominal tissue or prior abdominal surgeries.

Dallas Cancer Breast Reconstruction Patient Stories

My breast cancer surgery involved the removal of my left breast and a portion of the muscle underneath.  I was told that I had to wait 2 years before I could have reconstructive surgery so I had plenty of time to research my options.  The internet is a great source of information and I found more than enough to help me decide on the type of surgery I wanted.I considered a tram flap but really didn’t want the risk of future problems because of the missing muscle.  None of the doctors in my hometown would do any surgery more complex so I found Dr. Duffy.  I was interested in the DIEP flap, which although a much more complex surgery, I felt I would be more comfortable with the result.

I did not want an implant because I wanted the new breast to be made of my tissue.  Being a cancer survivor I did not want a foreign substance in my body.  The DIEP seemed ideal.  It would be natural and it would respond to changes in my body just like a regular breast.

The surgery was about 6 hours long.  Recovery was not painful.  I had to stay in bed at the hospital for a week, which is standard.  It was pretty much pain free except for when I had to move around or cough.  A ‘tummy tuck’ had been performed so that my abdomen could be used to fashion a new breast.  Those abdominal muscles were very sore, and it was hard to straighten up for a while.  I went home with drain tubes which weren’t hard to take care of.  Within a week of being home I was moving around pretty well and I was ready for the drain tubes to come out!

After I had recovered sufficiently from that surgery I returned to have my ‘old’ breast lifted to match my reconstructed breast.  At that time they also fashioned a nipple and areola for the reconstructed breast.

I gained weight after the surgery, putting on at least 30 pounds, but the reconstructed breast grew right along with me.  I eventually lost not only the 30 pounds, but an additional 30 pounds and the breast lost weight with me.  That wouldn’t have happened with an implant.

I couldn’t be happier with my DIEP flap reconstructed breast.  The tummy tuck was the icing on the cake!  Because of the reconstructed breast and the breast lift, my breasts do not look like the breasts of a 57 year old.  My flat stomach also doesn’t belong to the normal 57 year old.  Thank you Dr. Duffy!


My name is Marti. I had breast cancer and chose Dr Duffy to do my reconstruction (recommended by my breast doctor). My heart goes out to women who have breast cancer too, as a sister. After 6 months of chemo I was faced with the choices of surgery and reconstruction options. Honestly, it was overwhelming—I didn’t know what to expect or what the outcome would be.

After speaking to friends and researching, I chose to have the DIEP breast flap reconstruction. Dr Duffy did the reconstruction at the same time the mastectomy procedure was done. When I woke up I had a man-made breast in the place that would have been just a void. (I also had an abdominal incision that went from hip-to-hip–that’s where the fat, skin, and blood vessels to build the breast came from). 8-months later (after the tissue healed) I had the nipple reconstruction done–I know it sounds weird, but I felt the breast looks rather odd without a nipple. At that time I also chose to have bilateral breast implants in order to make both breasts the same size.

Several months later I asked Dr Duffy to tweak the procedure again (maybe I’m picky) but now I have a feminine bust line with a flat tummy. Under close inspection that breast is not perfect, but it resembles a natural breast in shape, size, and has the appearance of a small nipple. The scars are fading. I’m not afraid to wear sundresses or a two piece swimsuit for that matter.

I can’t speak for all womankind, but for me this was the best decision I could have made. My advice to patients is to get some more opinions from other patients—see what they say. When I was trying to decide, I spoke to a friend that had the TRAM done–she wished she had done the DIEP. It’s a very personal decision, and only you can decide.


Additional Resources
PDF Brochure of the DIEP Flaps
DIEP Insurance Information

Options for reconstruction with all natural tissues from abdomen & other sites

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